IL MONITORAGGIO NEI TUMORI DEL TROFOBLASTO DI ORIGINE GESTAZIONALE - PowerPoint PPT Presentation

1 / 28
About This Presentation
Title:

IL MONITORAGGIO NEI TUMORI DEL TROFOBLASTO DI ORIGINE GESTAZIONALE

Description:

E Garavaglia, HSR, Milan. Suction curettage of the uterine cavity with ultrasonography ... E Garavaglia, HSR, Milan. HOW LONG SHOULD PATIENTS BE FOLLOWED AFTER ... – PowerPoint PPT presentation

Number of Views:72
Avg rating:3.0/5.0
Slides: 29
Provided by: slog
Category:

less

Transcript and Presenter's Notes

Title: IL MONITORAGGIO NEI TUMORI DEL TROFOBLASTO DI ORIGINE GESTAZIONALE


1
CARAVAGGIO 15-17 MAGGIO 2008 MANAGEMENT AND
FOLLOW-UP AFTER MOLAR PREGNANCY
G. Mangili, E. Garavaglia, S Montoli, C
Gentile, R Vigano, E Rabaiotti, P De Marzi, M
Petrone, F Pella, D. Spagnolo, L. Valsecchi, P.
Cavoretto A Ferrari
Dipartimento Materno Infantile , UF Ginecologia
Oncologica IRCCS San Raffaele Milano
2
E Garavaglia, HSR, Milan
3
SURGERY
  • Suction curettage of the uterine cavity with
    ultrasonography
  • Intravenous oxytocin once evacuation is complete
  • Hysterectomy (in older patients?)
  • Attention to evacuation of late gestational
    miscarriages

E Garavaglia, HSR, Milan
4
(No Transcript)
5
FOLLOW UP
  • After molar evacuation, patients with molar
    pregnancy must be followed carefully to rule out
    development of postmolar GTN, by expertized
    clinicians
  • 5-30 persistent trophoblastic neoplasia (pGTN)
    (different observation times chosen by each
    center. (7 in our centre) Kohorn E et al. 1993.

E Garavaglia, HSR, Milan
6
FOLLOW UP AND ßhCG
  • in all gestational trophoblastic tumors from both
    the serum and the urine.
  • excellent indicator for recognizing malignant
    trasformation, checking the effectiveness of the
    treatment, relapse or progression
  • diagnosis of persistent trophoblastic disease is
    based traditionally upon serial ßhCG serum level
    measurements. Vaitukaitis
    JL et al. 1972

E Garavaglia, HSR, Milan
7
OLD SURVEILLANCE PROTOCOL
  • serial weekly hCG checks after 21 days after
    molar evacuation
  • Once undetectable titer is attained for 3
    weeks, monthly follow up is continued
  • for 6 months for partial moles
  • for 12 months for complete moles,
  • until 24 months for high risk patients (hCG
    negativization after 60 days or TVU positive)

E Garavaglia, HSR, Milan
8
HOW LONG SHOULD PATIENTS BE FOLLOWED AFTER MOLAR
PREGNANCY?
  • Questions
  • Is this long follow up clinically necessary?
  • Is still important differentiation between
    partial and complete mole for follow up?

E Garavaglia, HSR, Milan
9
PROLONGED ßhcg MONITORING
  • economic, social and emotional burden
  • postponement of fertility in women over 35
  • prematurely discontinuation of follow up
    (Schlaerth 19, Kim 27, Massad 81)

E Garavaglia, HSR, Milan
10
PROPHYLACTIC CHEMOTHERAPY
  • MOTIVATION reduction of incidence of pGTN
    (Goldstein from 20 to 8, Kim from 47 to 14)
  • OBJECTIONS
  • usefullness exposition to a chemotherapic agent
    (Hancock 1997)
  • incomplete protection to pGTN
  • false security
  • CONCLUSION if poor thecnological and economical
    resorses for follow up or where women have a low
    compliance.

E Garavaglia, HSR, Milan
11
IS PROLONGED MONITORING NECESSARY ?
  • In New England Trophoblastic Disease Center no
    pGTN when hCG lt 5 mIU/ml
  • in 1029 patients with CM
  • in 238 patients with PM
  • same result by Batorfi on 120 pts, Lavie on 74
  • In our center 1 pGTN on 230 (0.4) patients 3
    months after marker normalization (Kerkmeijer
    1/265)

E Garavaglia, HSR, Milan
12
CONCLUSIONS
  • If undetectable hCG values, risk of pGTN
    extraordinary low for CM and PM
  • gonadotropin follow up could be shortened for 97
    of patients.

E Garavaglia, HSR, Milan
13
IS PROLONGED MONITORING NECESSARY ?
  • In Trophoblastic Disease Unit in only one of the
    6701 women registered for hCG follow up the
    routine prolonged 2-year surveillance protocol
    detected pGTN
  • the modified 6-month surveillance protocol wuold
    detect more than 99 of all case of postmolar
    pGTN, while minimising the lenght of surveillance
    for the majority of women.

E Garavaglia, HSR, Milan
14
WHEN TO PROLONG FOLLOW UP
  • Two important prognostic factors to select high
    risk patients
  • - Ploidy
  • - the myometrial nodule

E Garavaglia, HSR, Milan
15
Risk of GTT
  • 162 diploid mole
  • 105 triploid
  • 17.3 diploid GTT
  • 0 triploid GTT

Niemann Obstet Gynecol 2006 1071006-11
  • The risk of GTT after triploid mole is low (from
    0 to 0.001)

7.5
16
TRANSVAGINAL ULTRASONOGRAPHY (TVU)
  • .

Mangili, Am J Obstet Gynecol 19931691218-23
17
PROGNOSTIC FACTORS
E.Garavaglia, HSR Milan
18
TVU - CONCLUSION
  • The risk of pGTN is increased in patients
    presenting myometrial invasions assessed by
    ultrasound after uterine evacuation.

E.Garavaglia, HSR Milan
19
TVU
  • At the beginning of follow-up
  • 178 (94 ) TVU negative
  • 189 pts
  • 9 myometrial nodule.

E.Garavaglia, HSR Milan
20
E.Garavaglia, HSR Milan
21
NEGATIVE TVU GROUP (178)
  • 7 (4 ) pGTN 6 non metastatic
  • 1 lung metastatis
  • after 8 weeks (range 7-16)
  • myometrial nodule 8.4 weeks (range 4-20)
  • ßhCG 13.533 (range 27 -55900)

E.Garavaglia, HSR Milan
22
POSITIVE TVU GROUP
  • 9 7 (78 ) pGTN
  • 2 marker normalization
  • (slow decline at the 72 and 91 day
    after evacuation)

E.Garavaglia,HSR Milan
23
HSR, Milan
24
HSR, Milan
25
HSR, Milan
26
CONCLUSIONS
  • Follow up must be prolonged in the presence of
    myometrial nodules
  • at the beginning of the follow up,
  • during follow up
  • normalization of myometrium is an indicator of
    disease resolution

E.Garavaglia,HSR Milan
27
REVISED SURVEILLANCE PROTOCOL OF HYDATIFORM MOLE
  • serial weekly hCG checks after 21 days after
    molar evacuation until return normal for 3
    consecutive weeks
  • Triploid stop follow up
  • HM until 6 months after evacuation
  • For 6 months after hCG normalization
  • - normal hCG gt 60 days after evacuation
  • - myometrial nodule presence

E.Garavaglia,HSR Milan
28
mangili.giorgia_at_hsr.it garavaglia.elisabetta_at_hsr.i
t

G. Mangili, E. Garavaglia, S Montoli, C
Gentile, R Vigano, E Rabaiotti, P De Marzi, M
Petrone, F Pella, D. Spagnolo, L. Valsecchi, P.
Cavoretto A Ferrari
Dipartimento Materno Infantile , UF Ginecologia
Oncologica IRCCS San Raffaele Milano
Write a Comment
User Comments (0)
About PowerShow.com